Healthcare Provider Details

I. General information

NPI: 1558440909
Provider Name (Legal Business Name): SAMANTHA DIANE LOCKE LPC-S,LMFT,MAC,MBACP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 04/26/2022
Certification Date: 04/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

YOUNGMINDED 27 OLD GLOUCESTER STREET
LONDON BERKSHIRE
WC1N 3AX
GB

IV. Provider business mailing address

27 OLD GLOUCESTER STREET
LONDON BERKSHIRE
WC1N 3AX
GB

V. Phone/Fax

Practice location:
  • Phone: 759-229-1220
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number507582
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2932
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1008
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: